BackgroundMoral dilemmas have arisen concerning whether physicians and other providers should treat patients who have declined COVID vaccination and are now sick with this disease. Several ethicists have argued that clinicians have obligations to treat such patients, yet providing care to these patients has distressed clinicians, who have at times declined to do so. Critical questions thus emerge regarding how best to proceed.Main bodyProviders face moral tensions: whether to place the benefits to an unvaccinated patient over their duties to protect (...) themselves and their families, staff and other patients, and goals of working collaboratively with patients. Clinicians’ duties to treat such patients arguably outweigh claims otherwise, but these obligations are creating moral conflict and distress for providers. Moral distress has been associated with burnout, post-traumatic stress disorder, and interpersonal and work difficulties. Given ongoing vaccine refusals, these problems are unlikely to disappear in the foreseeable future. Society has obligations to address this moral distress due to principles of reciprocity, and implicit social contracts, as part of which physicians risk their lives in caring for patients for the good of society as a whole. Responses are thus urgently needed at several levels: by hospitals, medical schools, professional societies, governments, media, providers and patients. Medical training on professionalism should address these stresses, probing why doctors have duties to treat these patients, but also how moral conflicts can ensue, and how best to address these tensions. Governments and institutions should thus alter relevant policies and devote more resources to addressing clinicians’ psychological strains. Institutions should also improve organizational culture. Public health organizations and the media described clinicians, earlier in the pandemic, as heroes, committed to treating COVID patients. This narrative should now be changed to highlight the strains that unvaccinated patients cause—endangering hospital staff and others.ConclusionsUnvaccinated COVID patients should receive care, but multi-level strategies, involving enhanced policies, education and practice are vital to alleviate ensuing moral distress, and thus aid these clinicians and their patients. Ethical arguments that providers must treat these patients have not considered these obligations’ effects on clinicians, but should do so. (shrink)

Definition of the problem The article asks whether vaccination status could become relevant if it is unavoidable to prioritize between patients in intensive care units during a pandemic. The aim is to analyze different approaches and arguments in favor of and against the inclusion of vaccination status. Arguments The following arguments are assessed: First, it has been argued that it is unnecessary to open this discussion. Second, one could make the point that public debates about touchy subjects should be avoided. (...) A third, frequently expressed opinion claims that physicians must never discriminate between vaccinated and unvaccinated patients, either because this is in conflict with human rights or because this is incompatible with the general principle that patients’ prior conduct does not matter. Fourth, behavioral economists argue that intensive care medicine should take vaccination status into account with the goal to improve the overall numbers of vaccinations. A fifth line of thinking argues that it is more just to take vaccination into account. Conclusion The author concludes that the omission to get a necessary and recommended vaccination may be taken into account if patients’ prospects to survive are similar. She points out that lotteries would be worse. (shrink)